Keon Kuk Kim

Splenic Abscess: A Single Institution Study and Review of the Literature

Purpose The aim of this study was to review our experience with splenic abscesses, with respect to the relevant aspects of splenic abscesses and treatment outcomes. Materials and Methods We reviewed the cases of 18 patients who had splenic abscesses and who were treated at our hospital from November 1993 to December 2008. Results The most common symptom at presentation was abdominal pain in 12 patients (66.7%). The median duration from symptom onset until establishment of a diagnosis was 22 days. Streptococcus viridians was the most common pathogen (27.8%), follow by Klebsiella pneumoniae (22.2%). The mortality rate during the inpatient period and the previous 90 days was 16.6%. Three of four patients with Klebsiella pneumoniae showed a single abscess pocket. Four patients (22.2%) underwent percutaneous drainage, eight (44.5%) recieved antibiotic treatment only and six (33.3%) underwent splenectomy. Conclusion There is no gold standard for treating splenic abscesses. Treatment should be customized for each patient.

The prognostic significant of percentage drop in serum CEA post curative resection for colon cancer

OBJECTIVE/BACKGROUND This study aimed to analyze the hypothesis that increased percentage drop in serum CEA post curative resection for colon cancer is associated with improved survival. METHODS Five hundred thirty three patients who underwent colon resection with a curative intent were retrospectively analyzed for their pre- and postoperative CEA levels. The disease-free and overall survival curves were calculated using Kaplan Meier analysis to evaluate cancer related outcomes. For multivariate analysis, the Cox regression model was used. RESULTS The estimated 5-year overall survival for the preoperative serum CEA > 5 ng/mL group with respect to a postoperative CEA level drop rate of 40%, 50% and 60% were 72.9%, 80.9% and 81.8%, respectively. The estimated 5-year overall survival for the preoperative serum CEA ≤ 5 ng/mL group with respect to each postoperative CEA level drop rate were 86.6%, 97.1% and 97.7%, respectively (P = 0.257, P = 0.092 and P = 0.073, respectively). The prognostic factors for poor survival were the depth of invasion (p = 0.042, hazard ratio: 2.617, 95% CI = 1.021-3.012) and lymph node metastasis (p = 0.008, hazard ratio: 2.249, 95% CI = 1.231-4.111). A 60% drop of the CEA level was an independent prognostic factor for survival (p = 0.001, hazard ratio: 2.954, 95% CI = 1.686-5.176) for patients with a preoperative CEA level > 5 ng/mL. CONCLUSION Determining the preoperative CEA level and the early postoperative percent drop of the serum CEA level may be a helpful factor for the prognosis of colon cancer patients. However, the percent drop from the pre to postoperative CEA level from the normal range was not associated with survival difference.

Factors influencing hepatocellular carcinoma prognosis after hepatectomy: a single-center experience.

Background/Aims Recurrence after hepatic resection is one of the most important factors impacting the prognosis and survival of patients with hepatocellular carcinoma (HCC). We identified prognostic factors affecting overall survival (OS) and disease-free survival (DFS) in patients with HCC after hepatic resection. Methods This study was of a retrospective cohort design, and 126 patients who underwent hepatic resection for HCC at Gachon University Gil Medical Center between January 2005 and December 2010 were enrolled. Various clinical, laboratory, and pathological data were evaluated to determine the prognostic factors affecting OS and DFS. Results Two- and 4-year OS and 2- and 4-year DFS were 78.1% and 65% and 51.1% and 26.6%, respectively. In a multivariate analysis, preoperative α-fetoprotein (> 400 ng/mL), tumor size (≥ 5 cm), multiple tumors (two or more nodules), presence of portal vein invasion, modified Union for International Cancer Control (UICC) stage III/IV, and Barcelona Clinic Liver Cancer (BCLC) stage B/C were independent prognostic factors affecting a shorter OS. In the multivariate analysis, presence of microvascular invasion, modified UICC stage III/IV, and BCLC stage B/C were independent prognostic factors for a shorter DFS. Conclusions The presence of vascular invasion was an independent poor prognostic factor for OS and DFS in patients with HCC after hepatic resection. Thus, close postoperative surveillance for early detection of recurrence and additional treatments are urgently needed in patients with vascular invasion after hepatic resection.

A Surgeon’s Perspective of Abdominal Wall Endometriosis at a Caesarean Section Incision: Nine Cases in a Single Institution

Abdominal wall endometriosis in a Caesarean section scar (AEC) is an infrequent type of extrapelvic endometriosis which rarely transforms into a malignant lesion. A painful mass located in the scar of a Caesarean section is a typical sign of AEC. This condition is diagnosed preoperatively using imaging modalities such as computed tomography and ultrasonography, as well as fine-needle aspiration. Although AEC has typical signs, general surgeons often misdiagnose it due to its rarity. Herein, we report our experience of AEC in a single institution.

Synchronous Peripancreatic Lymph Node Gastrinoma and Gastric Neuroendocrine Tumor Type 2.

A 34-year-old man was referred to our hospital with gastric polypoid lesions and biopsy-confirmed neuroendocrine tumor (NET). Computed tomography (CT) revealed a 3×3.5×8-cm retroperitoneal mass behind the pancreas, with multiple hepatic metastases. His serum gastrin level was elevated to 1,396 pg/mL. We performed a wedge resection of the stomach, a right hemi-hepatectomy, and a retroperitoneal mass excision. After careful review of the clinical, radiological, histopathological, and immunohistochemical findings, peripancreatic gastrinoma, and synchronous gastric NET were ultimately diagnosed. We reviewed a CT scan that had been performed 6 years previously after surgery for a duodenal perforation. There was no evidence of gastric or hepatic lesions, but the retroperitoneal mass was present at the same site. Had gastrinoma been detected earlier, our patient could have been cured using less invasive treatment. This case demonstrates how important it is to consider Zollinger-Ellison syndrome in patients with a recurrent or aggressive ulcer.

Iatrogenic Vascular Injury: Arteriovenous Fistula in NICU Neonates

Purpose: Invasive treatments have increased the risks of iatrogenic vascular injuries in neonates. Acute complications, such as thrombosis, rupture and pseudoaneurysm, require accurate diagnosis and prompt correction. In arteriovenous fistulas (AVFs) identified in time, some resolve spontaneously whereas others progress and cause major problems; potential growth disturbances and limb discrepancies. The paper is to evaluate the timing of surgery based on considerations of operation risk and expected clinical course in AVF neonates.Methods: We reviewed the charts of 2776 neonates admitted to the neonatal intensive care unit of the Department of Pediatrics of GMC over the 7-year period (Jan 2010-2017).Results: Eight (4 males, 4 females) had vascular lesions (0.29%). Mean gestational age was 196.4 days (range, 179-218 days), mean birth weight 985 g (range, 690-1340 g), mean gestational age at operation 352 days (range, 95-679 days), mean weight at operation 1825 g (range, 1230-2700 g), and mean time between diagnosis of fistula and operation 308 days (range, 41-646 days). Definite limb size discrepancy on simple radiographs was identified in 3 patients operated upon more than 1 year after being diagnosed with AVF. In 2 neonates aged between 6 months and 1 year, leg edema was evident and resolved postoperatively. In 3 neonates with simultaneous fistulas in both thighs, surgical correction was preferred for ipsilateral lesions with intense bruit on auscultation. Contralateral small fistulas resolved spontaneously in these 3 neonates within 6 months of initial AVF diagnosis.Conclusion: Early surgery should not be considered mandatory in all AVF neonates, based on considerations of long-term sequelae, the potential for iatrogenic injury to normal vascular structures and the wide-spectrum of clinical courses. Modulation of operative timing within the 6 months following diagnosis is reasonable as it does not increase risks of permanent impairment or sequela and can avoid unnecessary surgery.

A Case of Superior Mesenteric Artery Aneurysm Mimicking an Abdominal Aortic Aneurysm and Presenting as a Pulsating Abdominal Mass.

A 62-year-old male with a smoking history of 30 pack-years presented with a 1-year history of a periumbilical pulsating mass. He had been treated for hypertension for 2 years. Physical examination revealed a huge pulsating mass in the periumbilical abdomen. Femoral and popliteal arterial pulses were palpable. Computed tomography showed arterial dissection in the proximal segment of the superior mesenteric artery, a huge aneurysm (52×50 mm) with mural thrombus and two smaller aneurysms (20×20 mm) in the right ileocolic and ileal branches, along with atherosclerotic changes. Interposition using the great saphenous vein was performed after aneurysmal isolation and ligation of jejunal branches in the sac. Distal flow was reestablished by end-to-end and end-to-side anastomoses of the right ileocolic and ileal branches, respectively. No complications were observed at 1-year follow-up.